Increased stress is strongly correlated with greater acne severity a study of medical students published in Clinical, Cosmetic and Investigational Dermatology has found.
Although it is widely accepted that there is a relationship between stress and acne, few studies have assessed this relationship, so researchers at the medical faculty of King Abdulaziz University in Jeddah, Saudi Arabia looked at the relationship in 144 of the university’s sixth year female medical students, who were aged 22 to 24 years.
Students were asked to complete the Perceived Stress Scale (PSS). This 14-item self-questionnaire is widely used in stress research, and includes some confounding factors in acne severity, such as, menstruation, heat and humidity, sweating, use of makeup and cosmetic products, oily hair products, use of topical steroids, and squeezing pimples.
Once the students had completed the questionnaire they were examined by an intern, who had been trained by a consultant dermatologist, for the presence of acne lesions. Acne severity was graded according to the global acne grading system (GAGS), and the type of acne lesions present (comedones, papules, pustules, and nodules) and their location were noted.
Three students (2.1%) had no acne, 104 students (72.2%) had mild acne, 33 students (22.9%) had moderate acne, and 4 students (2.8%) had severe acne.
Increased stress severity was found to strongly correlated with increased acne severity, and this relationship was statistically significant (r=0.23; p<0.01). Of the eight acne aggravators included in the Perceived Stress Scale questionnaire, only excessive heat and humidity was found to have a statistically significant impact (p<0.05%).
The researchers said that heat and humidity may make it more favourable for Propionibacterium acnes to colonize the ductal hyperplasia.
While the study showed that there is an association between acne and stress levels, it did not prove a causative role for stress, commented Aryan Maleki, a medical student at Barts and The London School of Medicine and Dentistry, London, UK.ii
Acne is known to negatively affect quality of life and mood, so it is possible acne can lead to stress and not vice versa, he said. One way to establish a stronger causal relationship would be by evaluating whether stress-reduction techniques can significantly reduce acne severity.
“It would also aid in distinguishing whether the stress leading to acne originates from extrinsic factors or whether it is due to an individual’s ‘intrinsic’ predisposition to produce stress responses,” he said.
Shadi Zari, from the Faculty of Medicine at the University of Jeddah, in Saudi Arabia said that a number of mechanisms have been proposed mechanisms for how stress could aggravate acne.
In adult women with acne, chronic stress increases the secretion of adrenal androgens and results in sebaceous hyperplasia.
Activation of the hypothalamic–pituitary–adrenal (HPA) axis is the main adaptive response to systemic stress. In response to emotional stress, the HPA axis activates increased levels of cortisol release.
Corticotropinreleasing hormone (CRH) is the most proximal element of the HPA axis. CRH acts as a central coordinator for neuroendocrine and behavioural responses to stress. CRH stimulates sebaceous gland lipid production and steroidogenesis, which contributes to acne.
“Studies have also shown an increase of CRH expression in the sebaceous glands of acne-involved skin, compared to a low expression in normal skin. This upregulation of CRH expression in acne-involved skin may influence the inflammatory processes that lead to stress-induced acne lesions,” Zari said. “CRH also induces cytokines IL-6 and IL-11 production in keratinocytes, contributing to inflammation, which is regarded as a key component in the pathogenesis of acne.”
Furthermore, peripheral nerves release the neuropeptide substance P or vasointestinal peptide in response to stress. Substance P stimulates the proliferation and differentiation of sebaceous glands and upregulates lipid synthesis in sebaceous cells.
For people with acne, psychological stress could delay wound healing, which could affect the repair of acne lesions, Zari added.
Zari S, Alrahmani D. The association between stress and acne among female medical students in Jeddah, Saudi Arabia. Clinical, Cosmetic and Investigational Dermatology 2017;10: 503–506
Maleki A, Khalid N. Exploring the relationship between stress and acne: a medical student’s perspective. Clinical, Cosmetic and Investigational Dermatology 2018;11: 173–174.